R501-19A-5. Policies, Procedures, and Safe Practices

(1) Each provider shall develop, implement, and comply with policies, procedures, and safe practices for: (a) behavior management; (b) gender non-discrimination; (c) identifying and responding to a child in crisis; and (d) suicide prevention. (2) The provider shall ensure staff receive training on the policies, procedures, and safe practices described in this section. (3) The provider shall ensure compliance with the policies, procedures, and safe practices described in this section by: (a) submitting the required policies, procedures, and safe practices to OL during initial and renewal licensure and when any policy change requires approval; and (b) making any policy, procedure, or safe practice available upon request to OL and a client's parent or legal guardian. (4) The provider shall ensure any policy, procedure, and safe practice is trauma-informed. (5) The provider shall provide staff guidance regarding: (a) the appropriate response to any inappropriate behavior from other staff or a client; (b) the appropriate use of restraint, any emergency safety intervention, and seclusion; (c) prohibition of chemical and mechanical restraint unless approved by OL; (d) when a client poses a risk of violence; (e) what constitutes contraband and how the provider ensures restriction of any contraband and dangerous weapon or material; (f) appropriate client body cavity and strip search techniques, in alignment with Subsection 26B-2-123(1)(a), including that any body cavity or strip search: (i) cannot be a standard practice; and (ii) shall only be conducted by a licensed medical professional outside the view of any direct care staff; (g) critical incident reporting policy, in alignment with Rule R380-600 and Subsection 26B-2-124(1)(c); (h) any emergency procedure during any natural disaster, extreme weather event, fire, utility or structural failure, or other unexpected disruption, including: (i) continuity of care; (ii) critical incident reporting; and (iii) transport, relocation, and client health and safety; (i) how to recognize and report abuse and neglect; (j) how to report and respond to significant criminal activity or any significant medical emergency; (k) the least restrictive staff response to a client leaving the program without permission; (l) how to file a staff grievance and how to direct a client grievance; (m) the management of any unique provider circumstance regarding client supervision, the physical facility, community safety, and comingling populations; (n) firearm policy; (o) food service policy, including: (i) how to identify and accommodate any client with special dietary needs; (ii) if the program restricts access to food and kitchen equipment, an allowance for nutritious snacks to be available during restricted hours; and (iii) if any client participates in meal preparation, a policy that addresses: (A) any menu planning and procedure; (B) any nutrition requirement; (C) any sanitation requirement; (D) required training for safe food handling practices with a requirement for documented justification of each client's participation; and (E) any program rule or privilege involving kitchen use; (p) how to prevent and control any infectious and communicable disease, including coordination with and following the guidance of state or local health authorities, Center for Disease Control and Prevention, and the Department of Health and Human Services (department); and (q) provider and client responsibility for medication, including how to: (i) administer medication, including any self-administration process; (ii) log each medication dose; (iii) record and report any medication error; (iv) monitor and record any intended effect and side effect of medication; (v) record each medication dosage according to any prescription; (vi) store and administer medication on-site; (vii) store and administer medication when a client is in an off-site program-related activity; (viii) properly dispose of any unused or expired medication; and (ix) ensure the individual responsible for the discharge of a client is given any unused medication. (6) The provider shall train staff and ensure the use of any alternative sleeping arrangement, outside the client's assigned bedroom, complies with the suicide prevention plan, as described in Subsection 26B-2-124(4)(a)(iii). (a) Any alternative sleeping arrangement shall: (i) preserve client dignity and confidentiality; and (ii) be done on an individualized, time delimited basis. (b) Any alternative sleeping arrangement may not be used: (i) as a behavior management technique or as a consequence for behavior; (ii) to address any staffing shortage; or (iii) for staff convenience. (7) The provider shall preserve the rights of each client who receives congregate care residential treatment services. (8) The provider shall ensure there is a policy addressing management of client funds that requires documentation of each deposit and expense. (9) The provider shall ensure there is a policy addressing the care, licensure, maintenance, and vaccination of any on-site animal in accordance with any local ordinance, including the: (a) assessment of any pet allergy for any client interacting with any animal in the program; (b) maintenance of any required examination, registration, and vaccination of each animal; and (c) supervision of any client in the presence of an animal.